=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114346681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW DAVID WILSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2014
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 RAINBOW BLVD. 6040 DELP, MS 1020 DIVISION OF GENERAL AND GERIATRIC MEDICINE
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66160-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-588-6005
-----------------------------------------------------
Fax | 913-588-3877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3901 RAINBOW BLVD. 4070 DELP, MS 4017 KANSAS UNIVERSITY PHYSICIANS, INC.
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66160-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-588-2501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 0440000
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------